Provider Demographics
NPI:1689491656
Name:MINNIS, PAULINE MUMBUA
Entity type:Individual
Prefix:
First Name:PAULINE
Middle Name:MUMBUA
Last Name:MINNIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17814 110TH PL SE
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6560
Mailing Address - Country:US
Mailing Address - Phone:206-458-4069
Mailing Address - Fax:
Practice Address - Street 1:11410 NE 122ND WAY
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-6945
Practice Address - Country:US
Practice Address - Phone:425-650-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60350587163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse